Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system is effective for long-term management of adenomyosis.

BACKGROUD: Laparoscopic adenomyomectomy combined with intraoperative placement of levonorgestrel-releasing intrauterine device (LNG-IUS) is a novel conservative surgical procedure for adenomyosis. Our study aimed to compare the efficacy of surgery with or without intraoperative placement of LNG-IUS treatment in adenomyosis. METHODS: We retrospectively reviewed the medical records of adenomyosis patients who received laparoscopic adenomyomectomy from January 2014 to April 2020, finally including 70 patients undergoing surgery-LNG-IUS as group A and 69 patients undegoing surgery only as group B. Risk factors for three-year relapse were analyzed using Cox's multivariate proportional hazard analysis. RESULTS: Visual analog scale and Mansfield-Voda-Jorgensen Menstrual Bleeding Scale scores of group A at 3, 6, 12, 24, and 36 months were significantly lower than those of group B at the corresponding points (P < .001 for both scales). Individuals in both groups showed statistically significant symptom relief. The recurrence rate in group A was significantly lower than that in group B at 36 months after the surgery (2.94% vs. 32.84%, P < .001). A cox proportional hazard model showed that relapse was significantly associated with coexisting ovarian endometriosis (adjusted hazard ratio [aHR], 2.94; 95% confidence interval [CI], 1.33-7.02, P = .015). Patients who received surgery-LNG-IUS had a lower risk of recurrence than those with surgery-alone (aHR, 0.07; 95% CI, 0.016-0.31, P < .001). CONCLUSIONS: Conservative surgery with intraoperative placement of LNG-IUS is effective and well-accepted for long-term therapy with a lower recurrence rate for adenomyosis. Coexistent ovarian endometriosis is a major factor for adenomyosis relapse.

Surgical Efficacy among Laparoscopic Ultrasonic Dissectors in Adenomyosis.

OBJECTIVES: The present study aimed to investigate the efficacy of ultrasonic dissectors for adenomyomectomy using the double/multiple-flap method combined with temporary occlusion of the temporary bilateral uterine artery and the utero-ovarian vessels for the treatment of symptomatic adenomyosis. DESIGN: This was a retrospective study. PARTICIPANTS: In total, 162 patients with symptomatic adenomyosis were included, and all of them had originally been scheduled to group A (n = 82) and group B (n = 80) with each group representing a different surgical application. All eligible women were informed of the potential complications, benefits, and alternatives of each approach before they were assigned to one of the two groups, and patients chose group A or group B by themselves. In group A, we performed laparoscopic ultrasonic dissectors in adenomyosis with the double/multiple-flap method combined with temporary occlusion of the bilateral uterine artery and utero-ovarian vessels, while in group B, we performed adenomyomectomy with scissors. During the period of treatment, we evaluated operative time, intraoperative blood loss, and the degree of fatigue of surgeons' fingers. RESULTS: The estimated blood loss, operative time, and the degree of fatigue of surgeons' fingers in group A were significantly lower than that in group B (p < 0.001). No serious perioperative complications were observed in either group. LIMITATIONS: This was a retrospective study. CONCLUSION: The use of ultrasonic dissectors in laparoscopic adenomyomectomy with temporary occlusion of the bilateral uterine artery and the utero-ovarian vessels leads to improvements and releases the fatigue of surgeons' fingers in laparoscopic adenomyomectomy.

Uterus sparing surgery in adenomyosis and its impact on reproductive outcomes.

OBJECTIVE: The purpose of this study was to evaluate the appropriate surgical treatment of adenomyosis and its impact on reproductive outcomes. CONCLUSION: Patients with adenomyosis and fibroids may show a lower pregnancy rate and higher miscarriage rate than healthy individuals. However, there is no standard protocol for their optimal treatment, particularly in pregnancy-seeking or infertile women. Myomectomy is generally a commonly performed procedure that preserves fertility. On the other hand, the role of surgery in extensive uterine adenomyosis remains controversial, because adenomyosis often involves the whole uterus diffusely. It is almost impossible to remove all pathological tissue from the surrounding myometrium. Therefore, this procedure is called debulking/cytoreductive surgery. However, adenomyomectomy has also become a more common type of surgical intervention in recent years.

Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system in the treatment of adenomyosis: Feasibility and effectiveness.

AIM: To evaluate the clinical efficacy and safety of laparoscopic adenomyomectomy combined with intraoperative replacement of levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of symptomatic adenomyosis. METHODS: This is a case-series study in a university medical center. A total of 52 patients with symptomatic adenomyosis were treated by laparoscopic adenomyomectomy combined with intraoperative replacement of LNG-IUS from January 2015 to July 2018. Visual analog scale, menstrual flow and uterine volume were compared before and after the surgery (3, 12 and 24 months). Meanwhile, LNG-IUS-induced adverse reactions (e.g. irregular vaginal bleeding, amenorrhea, expulsion, and perforation) were also recorded. RESULTS: All operations were successfully completed via laparoscopy without conversion to laparotomy. No severe complications were noted during the surgical procedure or follow-up period. The mean postoperative visual analog scale and menstrual flow scores and the volume of the uterus were significantly decreased (all P < 0.001) at 3, 12, and 24 months postoperatively, compared with preoperative scores. The clinical effective rates among the patients with dysmenorrhea were 98%, 96% and 96% at 3, 12 and 24 months after the operation, respectively. And the clinical effectiveness rate of menorrhagia was 97.6%, 95.2% and 95.2% at 3, 12 and 24 months after treatment, respectively. Among all related adverse reactions, amenorrhea was the most common (n = 12, 23.1%). There was one case of LNG-IUS perforation (1.9%) and two cases of expulsion (3.8%). CONCLUSION: Laparoscopic adenomyomectomy combined with intraoperative replacement of LNG-IUS is a novel and effective conservative surgical procedure for symptomatic adenomyosis treatment.

Use of Augmented Reality in Gynecologic Surgery to Visualize Adenomyomas.

Augmented reality (AR) is a surgical guidance technology that allows key hidden subsurface structures to be visualized by endoscopic imaging. We report here 2 cases of patients with adenomyoma selected for the AR technique. The adenomyomas were localized using AR during laparoscopy. Three-dimensional models of the uterus, uterine cavity, and adenomyoma were constructed before surgery from T2-weighted magnetic resonance imaging, allowing an intraoperative 3-dimensional shape of the uterus to be obtained. These models were automatically aligned and "fused" with the laparoscopic video in real time, giving the uterus a semitransparent appearance and allowing the surgeon in real time to both locate the position of the adenomyoma and uterine cavity and rapidly decide how best to access the adenomyoma. In conclusion, the use of our AR system designed for gynecologic surgery leads to improvements in laparoscopic adenomyomectomy and surgical safety.

National survey of uterine rupture in Japan: Annual report of Perinatology Committee, Japan Society of Obstetrics and Gynecology, 2018.

AIM: To clarify the frequency of occurrence of uterine rupture and its prognosis, a nationwide survey was performed. METHODS: Cases of uterine rupture recorded for a period of 5 years were included. RESULTS: There were 152 cases of uterine rupture with an incidence rate of 0.015%. The scarred uterine rupture cases were found to have a significantly earlier occurrence of uterine ruptures in comparison to the unscarred cases: unscarred 39.0 weeks, cesarean section 37.0 weeks, myomectomy 32 weeks and adenomyomectomy 30-32 weeks. And it became apparent that the frequency of hysterectomy, cerebral palsy and neonatal death were higher in the cases of uterine rupture during labor than before delivery. Among the cases of scarred uterine rupture, neonatal prognosis was poorer in cases of pregnancy after myomectomy or adenomyomectomy in comparison with postcesarean section cases. CONCLUSION: This survey revealed the current incidence of uterine rupture in Japan.

Operation, hormone therapy and recovery of the patients with severe forms of adenomyosis.

Endometriosis is among the prevalent gynecological diseases and diagnosed in 10% of women of reproductive age. Endometriosis/adenomyosis is becoming increasingly a health-social problem, which is associated with severe clinical manifestations and recurrent disease which has a negative effect on quality of life, women ability to work and her reproductive function. This article presents modern approaches of drug therapy to treat severe forms of adenomyosis. We have reviewed recent major studies in the field of surgical treatment of this disease, analyzed the main stages of disease progress and the results of our surgeries. Here, we are presenting our own results of long-term post-operative hormonal therapy and complex medical treatment.

Conservative Surgery for Adenomyosis and Results: A Systematic Review.

The traditional treatment for women with symptomatic adenomyosis is hysterectomy. However, reproductive-aged women should be managed with less invasive treatments including medical treatment. For patients who are refractory or unsuitable to long-term medical treatment or those with focal adenomyoma, conservative surgeries could be offered. The objective of our study was to review available conservative surgeries for the treatment of adenomyosis, their complications, and the rates of success and recurrence. In this systematic review we evaluated 27 studies; 10 prospective and 17 retrospective studies including a total of 1398 patients. The results showed that excision of adenomyosis is effective for symptom control such as menorrhagia and dysmenorrhea and most probably for adenomyosis-related infertility. For preserving fertility and relieving symptoms, medical treatment is usually the first choice, whereas excisional surgery could be performed for refractory adenomyosis. The results show that over three-fourths of women will experience symptom relief after conservative surgery. The pregnancy rates after conservative surgical treatment vary widely. However, three-fourths of them conceived after surgery with or without adjuvant medical treatment. Depending on the duration of follow-up, recurrence rates differ from no recurrence to almost one-half of patients. Conservative surgery for adenomyosis improves pelvic pain, abnormal uterine bleeding, and possibly fertility. The best method of surgery is yet to be seen.

Conservative adenomyomectomy with transient occlusion of uterine arteries for diffuse uterine adenomyosis.

AIM: This study aimed to determine the feasibility and safety of adenomyomectomy with transient occlusion of uterine arteries (TOUA) in patients with symptomatic diffuse uterine adenomyosis. MATERIAL AND METHODS: Twenty-six patients with symptomatic diffuse uterine adenomyosis underwent adenomyomectomy with TOUA by a single surgeon at Ulsan University Hospital between May 2011 and September 2012. Surgical outcomes included operative time, intraoperative injury to blood vessels, nerves, and pelvic organs and operative blood loss. We assessed the degree of improvement in dysmenorrhea and menorrhagia at the 4-month follow-up after completion of adjuvant gonadotrophin-releasing hormone agonist. RESULTS: The mean age of patients was 37.73 years (range, 27-49 years). The mean total surgical time was 95.0 min (range, 60-145 min; SD, 34.49). The mean estimated blood loss was 191.54 mL (range, 80-400 mL; SD, 110.91) and there were no cases of injury to the uterine arteries or pelvic nerves. The mean time of TOUA was 9.79 min (range, 6-16 min; SD, 2.74). The mean duration of hospital stay was 5.65 days (range, 4-7 days; SD, 0.85). There were no major complications requiring reoperation or readministration during the mean follow-up period of 13.5 months. At the 7-month follow-up after adenomyomectomy with TOUA, complete remission of dysmenorrhea and menorrhagia was observed in 94.4% and 100% of patients, respectively. CONCLUSIONS: Adenomyomectomy with TOUA could be a safe and effective surgical method in women with symptomatic diffuse uterine adenomyosis to preserve fertility.

Treatment of adenomyomectomy in women with severe uterine adenomyosis using a novel technique.

The advised treatment for severe adenomyosis is hysterectomy, but for patients wishing to preserve their uterus, novel conservative surgery, adenomyomectomy, can be performed. The technique needs to be developed to reduce spontaneous uterine rupture, adhesion and recurrence rates. This study aimed to investigate the safety and therapeutic outcomes of adenomyomectomy. Prospectively, 103 Iranian patients with documented severe adenomyosis were candidates for adenomyomectomy over a period of 7 years (from April 2004 to March 2011). The surgical procedure involved resection of adenomatosis lesions with a thin (⩽ 0.5 cm) margin (wedge-shaped removal) after sagittal incision in the uterine body. Reconstruction of the layers was performed and inverted sutures were used for the serosal layer ends. Of 103 patients, 55.34% presented with infertility, 16.50% with IVF failure, 8.74% with recurrent abortion and 19.42% with abnormal uterine bleeding. Of 70 patients who attempted pregnancy, naturally (n=21) or by assisted reproduction treatment (n=49), 30% achieved a clinical pregnancy, and 16 resulted in a full-term live birth. Dysmenorrhoea and hypermenorrhoea were reduced post surgery. Only one patient had relapsed adenomyosis. Adenomyomectomy is a conservative and effective treatment for adenomyosis. This study describes an efficient procedure to treat severe adenomyosis. Adenomyosis is uterine thickening that occurs when endometrial tissue, which normally lines the uterus, moves into the outer muscular walls of the uterus. The advised treatment for the severe forms of adenomyosis is hysterectomy (removal of the patient's uterus), but for the patient who wishes to preserve her uterus, a novel conservative surgery referred to as 'adenomyomectomy' (removal of the abnormal tissues) can be performed. This technique must be developed for reduction of spontaneous uterine rupture, adhesions and recurrence rate. This study aims to investigate the safety and therapeutic outcomes of adenomyomectomy. Prospectively, 103 Iranian patients with documented severe adenomyosis were candidates for adenomyomectomy over a period of 7 years (from April 2004 to March 2011). The surgical procedure was resection of adenomatosis lesions with a thin margin. Of 103 patients, 55.34% presented with infertility, 16.50% with IVF failure, 8.74% with recurrent abortion and 19.42% with abnormal uterus bleeding. Of 70 patients who attempted pregnancy either naturally (n=21) or using assisted reproduction technology (n=49), 30% became pregnant, and 16 pregnancies reached full term. There was a significant reduction in dysmenorrhoea and hypermenorrhoea. Only one patient had relapsed adenomyosis. Based on these results, we conclude that adenomyomectomy is the conservative and effective option to treat adenomyosis with preservation of the uterus. The procedure described in this study can be an efficient procedure to treat severe adenomyosis.

Adenomyosis and fertility-sparing surgery: A literature appraisal.

Adenomyosis is an intricate pathological condition that negatively impacts the uterus. It is closely related to the more well-known endometriosis, with which it shares parallels in terms of diagnosis, therapy, and both microscopic and macroscopic features. The purpose of this narrative review is to give a clear univocal definition and outlook on the different, patient-adapted, surgical treatments. MEDLINE and PubMed searches on these topics were conducted from 1990 to 2022 using a mix of selected keywords. Papers and articles were identified and included in this narrative review after authors' revision and evaluation. From the literature analysis, authors reported the following surgical techniques: laparoscopic double/triple-flap method, laparotomic wedge resection of the uterine wall, laparotomic transverse H-incision of the uterine wall, laparotomic wedge-shaped excision, and laparotomic complete debulking excision by asymmetric dissection technique. Each of these techniques has strengths and weaknesses, but the literature data on the pregnancy rate are somewhat limited. The only certain information is the risk of uterine rupture up to 6.0% after surgical treatment for uterine adenomyosis. Over the years, the surgical approach continued to reach a positive result by minimally invasive treatment, with less hospitalization, less postoperative pain, and less blood loss. Over the years, the gynecological surgeon has gained the skills, training and increasingly sophisticated surgical techniques to target effective therapy. That's why a hysterectomy is no longer the only surgical resource to treat adenomyosis, but in patients who wish to preserve the fertility, there is a wide variety of surgical alternatives.

Prepregnancy Hysteroscopic Image in a Patient in whom Spontaneous Uterine Rupture Occurred in the 27th Week of Pregnancy after Adenomyomectomy.

We describe a preconception hysteroscopic image of a patient with a ruptured uterus at 27 weeks' gestation. A 40-year-old gravida 2, para 1, underwent open adenomyomectomy because of infertility. Subsequently, hysteroscopy performed at our hospital revealed an endometrial deficit from the uterine fundus to the posterior wall, and an area where the endometrium was missing and composed of yellow tissue was seen. She later achieved pregnancy. Lower abdominal pain occurred on day 1 of the 27th week of pregnancy. She suddenly went into a state of shock. Emergency laparotomy was performed, and a uterine rupture wound of approximately 10 cm in the longitudinal direction was seen in the posterior wall. A 1120-g male infant was stillborn. Total blood loss was 6450 mL. The mother was saved without hysterectomy. After adenomyomectomy, a hysteroscopy should be performed to check for endometrial defects before allowing pregnancy.

Uterine Rupture With Placenta Percreta Following Multiple Adenomyomectomies.

Pregnancy following adenomyomectomy is challenging because uterine rupture or placenta accreta spectrum (PAS) is more likely to occur; however, optimal management has not yet been established. We herein present a case of uterine rupture with placenta percreta in a pregnant woman who underwent adenomyomectomy twice before pregnancy. Magnetic resonance imaging (MRI) was performed in the second trimester and imminent uterine rupture concomitant with PAS was suspected. The patient was immediately admitted to hospital for careful management. Although failed tocolysis forced delivery at 29 weeks of gestation, managed hospitalization allowed cesarean hysterectomy to be performed uneventfully. Extensive PAS was proven pathologically in the removed uterus. Pregnancies following multiple adenomyomectomies are considered to be high-risk. Therefore, a sufficient explanation of the risks associated with future pregnancies is needed, particularly following second adenomyomectomy.

Effectiveness of Laparoscopic Adenomyomectomy on Perinatal Outcomes.

Objectives: The objective of this study was to observe the influence of laparoscopic adenomyomectomy on perinatal outcomes. Materials and Methods: The retrospective cohort study included 43 pregnant cases with adenomyosis who did not undergo laparoscopic surgery before pregnancy (nonsurgery group; 26 cases) and did (surgery group; 17 cases). To evaluate the impact of surgery on perinatal outcomes, nine obstetric complications including preterm delivery, hypertensive disorder of pregnancy, placental malposition, oligohydramnios, gestational diabetes mellitus, uterine rupture, abruptio placentae, and postpartum hemorrhage were selected. One obstetric complication was counted as one point (Maximum 9 points for one person). The obstetrical morbidity was compared by adding up the number of relevant events (0-9) between the two groups. Apgar score, umbilical artery pH (UApH), neonatal intensive care unit (NICU) admission, and neonatal death were also examined. Results: The surgery group had a significantly lower prevalence of fetal growth restriction compared to the nonsurgery group (nonsurgery vs. surgery; 26.9%, 7/26 vs. 0%, 0/17: P = 0.031). No differences were found in the morbidity of the nine obstetric complications (19.2%, 45/234 vs. 13.7%, 21/153), gestational weeks (mean ± standard deviation, 37.2 ± 2.4 vs. 36.4 ± 3.2), birth weight (2573.6 ± 557.9 vs. 2555.4 ± 680.8 g), Apgar score (1, 5 min; 8.0 ± 0.7 vs. 7.7 ± 1.2, 8.9 ± 0.6 vs. 8.5 ± 1.8), UApH (7.28 ± 0.08 vs. 7.28 ± 0.06), NICU admission (26.9%, 7/26 vs. 41.2%, 7/17), and neonatal death (0%, 0%) between both groups. Conclusion: Laparoscopic adenomyomectomy may not increase obstetric complications, although attention must be paid to uterine rupture during pregnancy.

Outcome of uterine functional structures protection by fertility preservative PUSH surgery in diffuse adenomyosis.

This study reports the outcomes of an innovative fertility-preserving surgery for the treatment of diffuse adenomyosis that is known as a surgery for protection of uterine structure for healing (PUSH Surgery). Developed at Peking University Shenzhen Hospital, PUSH Surgery aims to achieve radical excision of adenomyotic lesions by reconstructing the uterus with overlapping muscle flaps to promote optimal healing of the uterine wall and reduce the risk of scar rupture in subsequent pregnancies. PUSH Surgery was performed on 146 patients with diffuse adenomyosis, with uteri measuring from 8 to 16 gestational weeks and an average volume of 230 ± 150cm³. Regular follow-up was conducted for up to 156 months, revealing a significant reduction in VAS pain scores from 9.4 ± 1.2 before the surgery to 0.3 ± 0.8 and 0.6 ± 1.0 at 1 and 2 years post-surgery, respectively, with a continuous alleviation rate of 96.4% after the operations. Notably, 100% of patients with severe menorrhagia reported normal menstruation volumes within 2 years. Additionally, 31 patients attempted to conceive, resulting in a 58% postoperative pregnancy rate and a 60.0% intrauterine live embryo rate. Operation-related complications occurred in 2.7% of patients, with a 3.6% recurrence rate after more than 2 years of follow-up. Importantly, no cases of uterine rupture or severe complications were observed in the pregnant patients. In conclusion, PUSH Surgery offers a promising approach for the radical excision of adenomyotic lesions, promoting improved tissue healing and significant symptom relief.

A novel technique for myometrial defect closure after robot-assisted laparoscopic adenomyomectomy: A retrospective cohort study.

OBJECTIVE: To introduce our novel technique for myometrial defect closure after adenomyomectomy. MATERIALS AND METHODS: A retrospective cohort study. A total of 40 patients with adenomyosis who visited our clinic between October 2012 and January 2018 were recruited. Of those 34 patients were eligible for analysis. RESULTS: The mean thickness of the affected uterine wall before surgery was 4.02 cm ± 1.11, dropping to 2.37 cm ± 0.84 postoperatively. This led to a mean drop of 41% in the thickness of the affected wall, which was found to be significant using a paired t-test (p < 0.0001). The mean preoperative pain score was 8.68 ± 1.12, while the postoperative mean was 0.06 ± 0.34. The mean preoperative CA 125 was 121.73 ± 117.29, dropping to 6.95 ± 2.60 postoperatively. This was found to be significantly lower using both the Wilcoxon Signed Rank and Sign tests (p = 0.0156). CONCLUSION: Myometrial defect closure in a layer-by-layer fashion after robot-assisted laparoscopic adenomyomectomy is a reproducible technique. This uterine conserving method was effective in reducing our patients' pain. It may be the solution to maintaining adequate myometrial wall thickness, uterine layer alignment, and endometrial integrity.

Laparoscopic Adenomyomectomy under Real-Time Intraoperative Ultrasound Elastography Guidance: A Case Series and Feasibility Study.

BACKGROUND: This study aimed to examine the clinical characteristics of 11 patients undergoing laparoscopic adenomyomectomy guided by intraoperative ultrasound elastography and this technique's feasibility. PATIENTS AND METHODS: Eleven patients undergoing laparoscopic adenomyomectomy using ultrasound elastography for adenomyosis at Kawasaki Medical School Hospital in Okayama, Japan between March 2020 and February 2021 were enrolled. Operative outcomes included operative time, operative bleeding, resected weight, operation complications, percent change in hemoglobin (Hb) values, and uterine volume pre- and postoperatively. Dysmenorrhea improvement was evaluated by changes in visual analog scale (VAS) scores pre- and 6- and 12-months postoperatively. RESULTS: The median operative time and bleeding volume was 125 min (range, 88-188 min) and 150 mL (10-450 mL), respectively. The median resected weight was 5.0 g (1.5-180 g). No intraoperative or postoperative blood transfusions or perioperative complications were observed. The median changes in uterine volume, Hb value, and VAS score were -49% (-65 to -28%), -3% (-11 to 35%), and -80% (-100 to -50%), respectively. The median follow-up period post-surgery was 14 months (7-30 months). Adenomyosis recurrence was not observed in the patients during the follow-up period. CONCLUSIONS: Laparoscopic adenomyomectomy using ultrasound elastography guidance is minimally invasive and resects as many adenomyotic lesions as possible.

Fertility-sparing surgery for diffuse adenomyosis: a narrated, stepwise approach to the Osada procedure.

OBJECTIVE: To equip reproductive surgeons with an approach to the Osada procedure and critical prophylactic hemostatic measures that optimize perioperative outcomes. DESIGN: Stepwise demonstration of the Osada procedure with narrated video footage. SETTING: Definitive management of symptomatic adenomyosis requires hysterectomy. However, adenomyomectomy can improve symptoms and restore anatomy while maintaining fertility potential. Limited but comparable perioperative outcomes exist for minimally invasive methods of adenomyomectomy, and most involve resection of focal, not diffuse, adenomyosis. Among the literature involving resection of diffuse adenomyosis using minimally invasive methods, relatively small volumes of resected tissue are reported and none include obstetric outcomes. Most published reports for excision of diffuse adenomyosis involve laparotomic resection, likely because of specific intraoperative challenges curtailed by this approach. In response, a laparoscopic-assisted laparotomic approach was developed in 2011 by Dr. Hisao Osada, a reproductive surgeon in Japan. This procedure involves aggressive excision of adenomyotic tissue with prophylactic hemostatic techniques and subsequent uterine wall reconstruction using a triple-flap method. Compared with other excisional methods for diffuse adenomyomectomy, the Osada procedure has the best reported obstetric outcomes. PATIENT(S): A 37-year-old nulliparous female presented with pelvic pain, bulk symptoms, abnormal uterine bleeding, and infertility. Physical examination demonstrated a 20-week, bulky uterus with limited bimanual mobility. Her endometrial cavity was inaccessible because of marked anatomic distortion. Magnetic resonance imaging revealed marked abnormality of her endometrial contour because of a 15 cm adenomyoma with diffuse adenomyomatous tissue in the posterior uterine compartment. Prior interventions included a trial of combined hormonal contraceptive, leuprolide acetate, and tranexamic acid. She was interested in fertility-sparing adenomyomectomy to address symptoms and fertility potential and chose to proceed with the Osada procedure. She was optimized medically with oral and parenteral iron therapy to bring her hemoglobin from 55-111 g/L preoperatively. Institutional review board approval and informed consent from the patient were obtained. INTERVENTION(S): The Osada procedure was performed using the following 8 surgical steps: Systemic administration of tranexamic acid was also administered intraoperatively. MAIN OUTCOME MEASURE(S): Perioperative blood loss, anatomic normalization, symptom remediation, and maintenance of fertility potential. RESULTS: Perioperative blood loss was minimal, 469 g of adenomyotic tissue was extracted, and discharge was on postoperative day 2 without any complications. Three months later, cyclic pain and bleeding had improved markedly, ultrasound confirmed Doppler flow throughout the uterus, hysterosalpingogram demonstrated a nonobliterated endometrial cavity and tubal patency, and magnetic resonance imaging confirmed normalized uterine dimensions measuring 11 × 7 cm from 19 × 10 cm. Most literature supports waiting at least 6-12 months and until demonstration of normalized uterine blood flow in the operated area before attempting conception. CONCLUSION: Fertility-sparing excision of diffuse adenomyosis can be achieved safely using the Osada procedure, following the 8 discrete steps demonstrated in this video. Reproductive surgeons can reference this video to teach and maintain this important procedure.

A stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage.

OBJECTIVE: To propose a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage. DESIGN: A narrated video footage of the surgical approach of a clinical case with extensive adenomyosis and recurrent abortions. Institutional review board approval was obtained (No 3.725.458). SETTING: A university center. PATIENT(S): We present a case of a 37-year-old patient, gravida 4 para 0 with a history of 3 first trimester miscarriages after spontaneous pregnancies, and a 20-week spontaneous abortion after an in vitro fertilization pregnancy. She underwent 2 laparoscopic excisions of deeply infiltrative endometriosis and was treated with gonadotropin-releasing hormone for 6 months and dienogest for a year with no improvement of her adenomyosis. Currently, she experiences moderate dysmenorrhea and desires future fertility. INTERVENTION(S): For 3 months, gonadotropin-releasing hormone analogues were used before performing the robotic surgery for adenomyosis resection and abdominal cerclage. (Step 1) Control the blood supply with a tourniquet placed lateral to the uterine arteries at the level of the internal cervical os, and a diluted solution of vasopressin 20% is administered at the area to be excised. (Step 2) Uterine incision: we use a vertical uterine incision with monopolar scissors, extended anteriorly and posteriorly. (Step 3) Resection of adenomyosis: carried with monopolar scissors using pure cut current. It is recommended that 0.5-1 cm of the myometrium is maintained around the uterine cavity as well as the serosa. (Step 4) Flap 1: interrupted sutures with vicryl 2.0 are used to approximate the inner myometrium close to the endometrial cavity, and a 2.0 barbed suture is used to approximate the inner myometrium of the contralateral side of the incision to the ipsilateral outer myometrium. (Step 5) Flap 2: another 2.0 barbed suture is used to approximate the outer myometrium of the contralateral side to the base of the repaired inner myometrial layer. (Step 6) Serosal closure: the serosa is approximated with a barbed suture in a baseball fashion before the tourniquet is released and hemostasis is ensured. (Step 7) Abdominal cerclage: a mersilene tape is placed medial to the uterine arteries at the level of the internal cervical os and a tape is tied anteriorly. MAIN OUTCOME MEASURE(S): Description of a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage. RESULT(S): The operating time was 255 min with minimal estimated blood loss (250ml). She was discharged with no complaints. Three months postoperatively, dysmenorrhea significantly improved, and the magnetic resonance imaging showed a good anatomic result. An embryo transfer is planned at 6 months postoperatively. CONCLUSION(S): A minimally invasive approach to fertility-sparing management of diffuse adenomyosis is safe and feasible with good anatomical results. However, it should be noted that after the removal of uterine adenomyosis, the patient should be advised on the high risk of uterine rupture during pregnancy. Robotic cerclage may also be performed concomitantly in cases of 2nd-trimester recurrent abortions.

Anti-Mullerian Hormone (AMH) and adenomyosis: Mini-review of literature of the last 5 years.

Introduction: Adenomyosis is a form of endometriosis characterized by the presence of endometrial tissue in the myometrium. The correlation between anti-Mullerian hormone (AMH) expression and adenomyosis is unclear. Few studies investigated this possible correlation with promising results. The aim of this mini-review is to illustrate the potential prognostic and therapeutic role of AMH in adenomyosis. Materials and methods: A study protocol was completed conforming to the Preferred Reporting Items for Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. We performed an electronic databases search from each database's inception from August 2017 to August 2022 for full-text articles and published abstracts. For database searches, the following main keywords were the following text words: "adenomyosis" or "uterine endometriosis" [Mesh] AND "AMH" or "anti-mullerian hormone". Results: From the literature search, 8 abstracts of studies were retrieved and independently screened for inclusion by three authors. It was found that the most common therapeutic strategies (such as adenomyomectomy and high-intensity focused ultrasound (HIFU) do not alter AMH levels. Moreover, a higher expression of the AMH receptor II was observed in adenomyotic tissue, hence a possible therapeutic use of AMH was hypothesized. Conclusion: The available evidence shows an unclear relationship between adenomyosis and AMH. Probably, women with adenomyosis have lower levels of AMH and the surgical treatment (adenomyomectomy, HIFU) does not alter this characteristic, therefore in all of them, ovarian function is not influenced.